DEBATE The endometriosis syndromes: a clinical classi®cation in the presence of aetiological confusion and therapeutic anarchy

Clinical confusion and inappropriate management continues to surround endometriosis. It is poorly recognized that the disorder can exist in two different morphological forms that have different symptoms, signs and prognosis. Earlier classi®cation systems have been useful for research but are of limited value in aiding day-to-day manage-ment. In the clinic, two discrete phenotypes can be de®ned by the presence or absence of palpable nodules in the deep pelvis. Patients with such nodules with or without associated ovarian endometrioma usually have severe symp-toms with signi®cant risks of bowel and urinary tract involvement. The predominant histological feature of these lesions is extensive ®bromuscular hyperplasia (adenomyoma). These patients will often need extensive surgical inter-vention. Patients without such palpable lesions usually have the classic super®cial subperitoneal lesions with endo-metrial-like glands and stroma on histological examination. This group often has less severe symptoms and has little risk of developing serious associated problems. These lesions may be helped by medications and/or simple ablative surgery. It is suggested that these collections of symptoms and signs or syndromes be named after the pioneers who ®rst described the lesions. Cullen's syndrome can be used to describe those patients with severe symptoms of endo-metriosis associated with palpable pelvic nodules. Sampson's syndrome can describe those with similar symptoms associated with a structurally normal pelvis.